Summary: The Care Provider took too long to submit a nursing assessment for Funded Nursing Care. This caused Mrs Y a financial loss because her fees were not reduced for three months. The Care Provider will apologise and reimburse Mrs Y.

The complaint

1. Ms X complained Amica Care Trust (the Care Provider) delayed in applying for Funded Nursing Care and this caused her relative Mrs Y a financial loss.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. I considered Mrs X’s complaint to us, letters from the Care Provider and documents in this statement.
5. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Guidance

6. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time.
7. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”. This says “where you are working with new organisations to deliver services during Covid, or using existing partners in new ways, ensure your organisation keeps proper oversight and direction.”
8. Funded Nursing Care (FNC) payments are towards the cost of nursing care by a registered nurse in a nursing home. A resident’s local NHS Clinical Commissioning Group (CCG) makes FNC payments to their nursing home. The resident does not receive any money directly, although payment of FNC may affect the amount a self-funder pays if their contract says the fee will be reduced if FNC is awarded. This is the case with the contract for Mrs Y’s care.
9. Funded Nursing Care Practice Guidance (2018) is guidance from the Government which says:
• An assessment by a registered nurse is needed to say whether someone is eligible for FNC
• CCGs are responsible for eligibility assessments.
10. Dorset CCG wrote to all nursing homes in its area at the end of August 2020 about FNC and continuing health care arrangements for assessing eligibility. I have summarised the main points of the letter below:
• All CCGs stopped doing face to face assessments and reviews during the pandemic. Government required CCGs to resume them from 1 September
• It would carry out reviews and assessments by video call
• For FNC assessments, the CCG would contact care providers with enough time before the virtual meeting and would advise of the process
• The 14-day period for submitting the change of circumstance and consent to apply for FNC forms was also paused during the pandemic and would restart from 1 September. It expected care providers to submit the relevant information to apply for FNC from 1 September.

What happened

11. Mrs Y is a self-funder. Ms X manages Mrs Y’s finances for her. Mrs Y moved to one of the Care Provider’s nursing homes at the start of November 2020. Before this, she lived in a nursing home in another area.
12. Ms X told us she completed a consent form for the CCG to assess Mrs Y for FNC on 16 November which the nursing home sent to the CCG on 23 November.
13. Ms X said she received a letter from the CCG in March 2021 saying it would pay FNC from 8 February which was the date it received the nursing home’s nursing assessment.
14. Ms X complained to the Care Provider in May. It replied in July saying:
• The application (assessment) was not sent until February, it did not know why there was a delay. There was an outbreak of COVID-19 in the nursing home though and this may have had a bearing on the delay
• The manager at the time met with the CCG and raised concerns about their processes. The CCG refused to backdate the award.
15. The Care Provider’s operations manager and Ms X met in October. After the meeting, the operations manger wrote to Ms X saying:
• She had spoken to the CCG and not yet complained formally
• The Care Provider was a charity and it should not be paying out for FNC that Mrs Y should have received from the start
• The nursing home acted correctly by referring Mrs Y for an FNC assessment and she was also getting FNC previously, so she should be entitled to FNC from the date of the referral to the CCG
• The Care Provider intended to complain to the CCG and to the Parliamentary and Health Service Ombudsman if necessary.
• Ms X could also complain to us.
16. The operations manager wrote to the CCG after the meeting, with a complaint about its failure to backdate Ms Y’s FNC payments to the date she moved into the nursing home. The letter went to say that:
• During the pandemic, all nursing homes were asked to complete the nursing needs assessment to apply for FNC, but this stopped in September 2020. So the nursing home went back to the original procedure which was to send just the consent form application.
• Mrs Y moved in to the nursing home on 3 November, so the nursing home completed the change of circumstances form and sent it on 4 November. It sent the consent application form for FNC on 23 November. This was in line with the process in place before COVID-19.
• Despite knowing the nursing home having a COVID-19 outbreak, the FNC team at the CCG said they needed the nursing home to complete the nursing assessment which it duly did and sent to the CCG on 8 February 2021.
• The CCG did not backdate the funding to November 2020, only to 8 February 2021 and this was not reasonable.
17. The CCG said in response to the operations manager that its policy was not to deal with the matter as a complaint because it was from a responsible body, but its commissioning team would reply to the email. I have not seen the reply, but the matter was not resolved when Ms X complained to us.

Findings

18. Normally, the CCG would complete nursing needs assessments for FNC. The government suspended this during the pandemic. The CCG’s correspondence at the end of August 2020 indicated its processes were going back to normal at the start of September. However, the CCG asked the nursing home to do Mrs Y’s nursing assessment despite the mandate from the government to revert to pre-COVID practice. I have no power to comment on the CCG’s actions.
19. The Care Provider accepted in its complaint response that it agreed to complete Ms Y’s nursing assessment and did not return the completed nursing assessment until February 2021. This was an unacceptable delay and was fault. I have taken into account the exceptional pressures on the nursing home during COVID-19, but I consider the service fell short of our expectations as I have summarised in paragraph seven. The nursing home did not maintain adequate oversight or direction over Mrs Y’s application for FNC. Having agreed to complete Mrs Y’s nursing assessment on behalf of the CCG, it should have done so in a reasonable timeframe. Taking three months was too long and was fault.
20. The delay caused a loss of FNC payments which would have reduced Ms Y’s overall charge. So she has a financial loss.

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Agreed action

21. The Care Provider will apologise to Ms X for the failings identified in this statement and refund Ms Y the value of the FNC payments (£2244). It will do so within one month of my final decision.

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Final decision

22. The Care Provider took too long to submit a nursing assessment for Funded Nursing Care. This caused Mrs Y a financial loss because her fees were not reduced for three months. The Care Provider will apologise and reimburse Mrs Y. I have completed the investigation because the agreed action remedies the injustice.
23. I have shared a copy of this statement with the Care Quality Commission in line with our information sharing agreement.

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Parts of the complaint that I did not investigate

24. I did not investigate complaints about the actions or failures of the Clinical Commissioning Group as it is not a body in our remit to investigate. We can only investigate the actions of the Care Provider.

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Investigator's decision on behalf of the Ombudsman